Sep 20, 2017

Repeal first, ask questions later

Illustration: Lazaro Gamio / Axios

Senate Republicans are on the verge of passing a sweeping health care bill not only without knowing what's in it, but without particularly caring. The political abstraction of "Obamacare" — and the seven years of promises to "repeal Obamacare" — have almost totally overshadowed even the broad strokes of policy, much less the details.

The bottom line: The repeal-and-replace bill sponsored by Sens. Lindsey Graham and Bill Cassidy is gaining steam because it has the appearance of gaining steam — not because of the changes it would make. "If there was an oral exam on the contents of the proposal, graded on a generous curve, only two Republicans could pass it. And one of them isn't Lindsey Graham," a senior GOP aide told Caitlin.

The big picture: The ACA had all sorts of unanticipated quirks and unintended consequences — and Democrats spent almost a year working on it. A bill written in a couple weeks, whose scope is even bigger than the ACA's, is sure to have some, too. And yet, many rank-and-file Republicans have barely reckoned with the very big things the bill would do intentionally.

  • "I am just in shock how no one actually cares about the policy any more," one GOP lobbyist told Caitlin.

The details: Graham-Cassidy would roll federal funding for the ACA's premium subsidies and Medicaid expansion into a single pot, reduce the overall size of that pot, and distribute it to states according to a complex formula. On top of that, it would impose new caps on federal Medicaid spending. Together, those cuts would dramatically roll back the federal government's role in health care and would almost surely lead to millions more uninsured people than the status quo.

The unknowns: The Congressional Budget Office says it will release a "preliminary assessment" of the bill early next week, but it won't include critical details like how the bill would affect premiums and the number of people with health insurance. So if the Senate votes before Sept. 30 — the deadline for being able to repeal the ACA through budget “reconciliation" rules — it won't have any of that information. (Independent estimates suggest that those effects would be staggering.)

But you don't hear a lot of Republicans worrying about that. They think CBO is too slow and has overstated the negative impact of the previous bills. "I think we can pretty well decide based on the information we already have," Sen Ron Johnson said yesterday on CNN.

How we got here: Graham-Cassidy would be the fourth repeal bill to get a vote in three months — if it gets one.

  • "This is like the Lazarus of health care bills. It's back, and I don't know exactly why that is," conservative policy analyst Douglas Holtz-Eakin — who's on board with many of the bill's policy goals — told Sam. "If it was just a policy argument, I don't think it would have come back."

Those bills vary significantly. None of Graham-Cassidy's predecessors in the Senate included a similar system of state block grants. Only one would have eliminated the ACA's premium subsidies; a different one would have made similar changes to Medicaid. Yet they all got between 43 and 49 votes.

  • "You could do a post office renaming and call it 'repeal-replace' and 48 Republican senators would vote for it sight unseen," the GOP aide said.

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